Provider Demographics
NPI:1164831988
Name:CASSIDY, KARI (MED, EDS)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404
Mailing Address - Country:US
Mailing Address - Phone:850-890-5328
Mailing Address - Fax:
Practice Address - Street 1:2711 W. 15TH STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1124518103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool